An immigration removal centre. The detainee’s suicide risk was found to be improperly assessed.
Photograph: Bruno Vincent/Getty Images

An immigration detainee killed himself two days after staff determined in a three-minute meeting that his distress was down to toothache, despite him telling them he wanted to die after being held for nearly a year, a custody watchdog has said.

The 28-year-old Polish national was remanded in prison custody on charges of assault and criminal damage, but due to his offending history was transferred to an immigration removal centre (IRC) – understood to be Harmondsworth – pending deportation.

He became increasingly distressed as it was unclear to him why he had been detained for so long, the Prisons and Probation Ombudsman (PPO) annual report said.

Staff placed him under suicide monitoring procedures, but the next day, a review concluded his distress was due to toothache and he was no longer a risk as a dental appointment was arranged.

Two days later, the detainee – referred to in the PPO report as Mr P – killed himself.

On Wednesday, the Guardian revealed more than half of 200 migrant detainees who responded to a snapshot survey were suicidal, seriously ill or victims of torture. Eight of the 188 people included in the analysis reported suicidal tendencies.

The PPO report said: “We found that Mr P’s risk of suicide was not properly assessed. There was a lack of information sharing between IRC staff and healthcare staff.

“Mr P was found to be under the influence of illicit substances on three occasions, but healthcare staff were not informed, and were not informed when Mr P was made subject to suicide and self-harm monitoring.

“Staff stopped monitoring prematurely and failed to consider restarting it when Mr P showed signs of further distress. We also found that although uncertainty about his continued detention contributed significantly to Mr P’s distress, this was not considered in the assessment of his risk.”

Born in the remote town of Cibórz, near Świebodzin in west Poland, Gwoździński – the youngest of seven brothers – arrived in the UK aged 23. In October 2016 – despite working on a building site in Tooting, south London – Gwoździński was sleeping rough near Streatham Common.

He smoked cannabis to help him sleep and one evening approached dealers near Streatham’s St Leonard’s Church to stock up on supplies. Gwoździński was short-changed, a scuffle broke out that was caught on CCTV. The following morning, he was arrested and taken to Harmondsworth.

In 2017-18, the PPO opened investigations into the deaths of five people in IRCs, of which three were suicides.

In addition, the watchdog launched inquiries into the deaths of four men who had killed themselves while being held in prisons under immigration powers. All four had completed their sentences, but were awaiting deportation.

In the UK, Samaritans can be contacted on 116 123 or email jo@samaritans.org. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international suicide helplines can be found at www.befrienders.org.